(1) State of licence issue:

(2) Medical certificate applied for: class 1   class 2   LAPL 

(3) Surname:

(4) Previous surname(s):

(12) Application Initial    

Revalidation/Renewal  

(5) Forenames:

(6) Date of birth (dd/mm/yyyy):

(7) Sex

Male    

Female    

(13) Reference number:

(8) Place and country of birth:

(9) Nationality:

(14) Type of licence applied for:

(10) Permanent address:

Country:

Telephone No.:

Mobile No.:

e-mail:

(11) Postal address (if different)

Country:

Telephone No.:

(15) Occupation (principal)

(16) Employer

(17) Last medical examination

Date:

Place:

(18) Aviation licence(s) held (type):

Licence number:

State of issue:

(19) Any Limitations on Licence/ Medical Certificate No    Yes  

Details:

(20) Have you ever had an aviation medical certificate denied, suspended or revoked by any licensing authority?

No    Yes    Date:                             Country:

Details:

(21) Flight time hours total:

(22) Flight time hours since last medical:

(23) Aircraft class /type(s) presently flown:

(24) Any aviation accident or reported incident since last medical examination?

No    Yes    Date:                             Place:

Details:

(25) Type of flying intended:

(26) Present flying activity:

Single pilot    Multi pilot    

(27) Do you drink alcohol?

 No    Yes, amount

(28) Do you currently use any medication?

No    Yes    State drug, dose, date started and why:

(29) Do you smoke tobacco?  No, never    No, date stopped:

  Yes, state type and amount:

1.    LICENSING AUTHORITY:

        State name of country this application is to be forwarded to.

17. LAST APPLICATION FOR A MEDICAL CERTIFICATE:

       State date (day, month, year) and place (town, country)
Initial applicants state ‘NONE’.

2.    MEDICAL CERTIFICATE APPLIED FOR:

18. LICENCE(S) HELD (TYPE):

        Tick appropriate box.

       State type of licence(s) held.

        Class 1: Professional Pilot

       Enter licence number and State of issue.

        Class 2: Private Pilot

       If no licences are held, state ‘NONE’.

        LAPL

3.    SURNAME:

        State surname/family name.

19. ANY LIMITATIONS ON THE LICENCE(S)/MEDICAL CERTIFICATE:

       Tick appropriate box and give details of any limitations on your licence(s)/medical certificate, e.g. vision, colour vision, safety pilot, etc.

4.    PREVIOUS SURNAME(S):

        If your surname or family name has changed for any reason, state previous name(s).

20. MEDICAL CERTIFICATE DENIAL, SUSPENSION OR REVOCATION:

       Tick ‘YES’ box if you have ever had a medical certificate denied, suspended or revoked, even if only temporary.

       If ‘YES’, state date (dd/mm/yyyy) and country where it occurred.

5.    FORENAME(S):

        State first and middle names (maximum three).

21. FLIGHT TIME TOTAL:

       State total number of hours flown.

6.    DATE OF BIRTH:

22. FLIGHT TIME SINCE LAST MEDICAL:

        Specify in order dd/mm/yyyy.

       State number of hours flown since your last medical examination.

7.    SEX:

23. AIRCRAFT CLASS/TYPE(S) PRESENTLY FLOWN:

        Tick appropriate box.

       State name of principal aircraft flown, e.g. Boeing 737, Cessna 150, etc.

8.    PLACE AND COUNTRY OF BIRTH:

        State town and country of birth.

24. ANY AVIATION ACCIDENT OR REPORTED INCIDENT SINCE LAST MEDICAL EXAMINATION:

       If ‘YES’ box ticked, state date (dd/mm/yyyy) and country of accident/incident.

9.    NATIONALITY:

25. TYPE OF FLYING INTENDED:

        State name of country of citizenship.

       State whether airline, charter, single-pilot, commercial air transport, carrying passengers, agriculture, pleasure, etc.

10.  PERMANENT ADDRESS:

26. PRESENT FLYING ACTIVITY:

        State permanent postal address and country. Enter telephone area code as well as telephone number.

       Tick appropriate box to indicate whether you fly as the SOLE pilot or not.

11.  POSTAL ADDRESS (IF DIFFERENT):

27. DO YOU DRINK ALCOHOL?

        If different from permanent address, state full current postal address including telephone number and area code. If the same, enter ‘SAME’.

       Tick applicable box. If yes, state weekly alcohol consumption e.g. 2 litres beer.

12.  APPLICATION:

28. DO YOU CURRENTLY USE ANY MEDICATION?:

        Tick appropriate box.

       If ‘YES’, give full details - name, how much you take and when, etc.

       Include any non-prescription medication.

13.  REFERENCE NUMBER:

29. DO YOU SMOKE TOBACCO?

        State reference number allocated to you by the licensing authority

        Initial applicants enter ‘NONE’.

       Tick applicable box. Current smokers state type (cigarettes, cigars, pipe) and amount (e.g. 2 cigars daily; pipe – 1 oz. weekly)

14.  TYPE OF LICENCE APPLIED FOR:

GENERAL AND MEDICAL HISTORY

All items under this heading from number 101 to 179 inclusive should have the answer ‘YES’ or ‘NO’ ticked. You should tick ‘YES’ if you have ever had the condition in your life and describe the condition and approximate date in the (30) remarks section. All questions asked are medically important even though this may not be readily apparent.

Items numbered 170 to 179 relate to immediate family history, whereas items numbered 150 to 151 should be answered by female applicants only.

If information has been reported on a previous application form for a medical certificate and there has been no change in your condition, you may state ‘Previously reported; no change since’. However, you should still tick ‘YES’ to the condition.

Do not report occasional common illnesses such as colds.

        State type of licence applied for from the following list:

        Aeroplane Transport Pilot Licence

        Multi-Pilot Licence

        Commercial Pilot Licence/Instrument Rating

        Commercial Pilot Licence

        Private Pilot Licence/Instrument Rating

        Private Pilot Licence

        Sailplane Pilot Licence

        Balloon Pilot Licence

        Light Aircraft Pilot Licence

        And whether Fixed Wing / Rotary Wing / Both

        Other – Please specify

15.  OCCUPATION (PRINCIPAL):

        Indicate your principal employment.

16.  EMPLOYER:

        If principal occupation is pilot, then state employer’s name or if self-employed, state ‘self’.

31. DECLARATION AND CONSENT TO OBTAINING AND RELEASING INFORMATION:

       Do not sign or date these declarations until indicated to do so by the AME/GMP who will act as witness and sign accordingly.